Provider Demographics
NPI:1710494646
Name:SIMMONS, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:WEST LEISENRING
Mailing Address - State:PA
Mailing Address - Zip Code:15489-0141
Mailing Address - Country:US
Mailing Address - Phone:724-562-9076
Mailing Address - Fax:724-438-3379
Practice Address - Street 1:920 N GALLATIN AVENUE EXT
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2112
Practice Address - Country:US
Practice Address - Phone:724-562-9076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1025571920002374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide